=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154142461
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRES J MEDINA GARCIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2024
-----------------------------------------------------
Last Update Date | 10/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5815 S MARYLAND AVE # 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-1463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-702-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1157 E 61ST ST APT 2
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-5923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-778-1702
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246QM0706X
-----------------------------------------------------
Taxonomy Name | Medical Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------